APPLICATION FOR
ME M B E R SH I P
Name
Occupation/Title
Company/Affiliation
Work Address
Street
City
State
Zip Code
Street
City
State
Zip Code
Residence Address
Preferred Mailing Address?
WORK
Work Phone
-or-
RESIDENCE
Residence Phone
Mobile Phone
Fax
Email
Member of AAPG?
YES
-or-
NO
Professional References – list two references with phone numbers and addresses
1) Name
Phone
Address
Street
City
2) Name
State
Zip Code
State
Zip Code
Phone
Address
Street
City
Education – list colleges and universities attended, degree(s) received, and date of degree(s) (OPTIONAL)
Membership Type
ACTIVE
ASSOCIATE
STUDENT
LIFE
Signature
$20.00/year
$15.00/year
$10.00/year
$200.00 (one-time payment)
Please make check payable to:
Nevada Petroleum and
Geothermal Society
P.O. Box 11526
Reno, NV 89510-1526
Date
DO NOT COMPLETE
For NPGS Membership Committee Signatures Only